A Comparison of Two Home Exercises for Benigna Potitional Vertigo.pdf

E X T R AAudiology Neurotology The Science of Hearing and Balance Audiol Neurotol Extra 2012;2:16–23 DOI: 10.1159/000337947 Published online: April 20, 2012 © 2012 S. Karger AG, Basel www.karger.com/aue 16 This is an Open Access article licensed under the terms of the Creative Commons AttributionNonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online version of the article only. Distribution for non-commercial purposes only. Original Paper A Comparison of Two Home Exercises for Benign Positional Vertigo: Half Somersault versus Epley Maneuver Carol A. Foster a Annand Ponnapan b Kathleen Zaccaro c Darcy Strong c Departments of a Otolaryngology and Audiology, b Otolaryngology, and c Audiology, School of Medicine, University of Colorado Denver, Aurora, Colo., USA Key Words Benign paroxysmal positional vertigo ⴢ Half somersault exercise ⴢ Epley maneuver Abstract Benign paroxysmal positional vertigo (BPPV) frequently recurs after treatment, so a home exercise would be desirable. We designed a self-administered exercise, the half somersault, for home use. In this randomized single-blind study, we compare the efficacy of our exercise to self-administered Epley maneuvers in patients with BPPV. Subjects performed exercises twice while observed, were re-tested with the Dix Hallpike, and then reported on exercise use for 6 months. Outcome measures were the reduction of nystagmus intensity, tolerability of induced dizziness, and long-term efficacy. Both exercises resulted in a significant reduction in nystagmus after two self-applications. The Epley maneuver was significantly more efficacious in reducing nystagmus initially, but caused significantly more dizziness during application than the half somersault. During the 6-month follow-up, the Epley group had significantly more treatment failures than the half somersault group. We believe that both exercises can be self-applied to control symptoms, but the half somersault is tolerated better and has fewer side effects as a home exercise. Copyright © 2012 S. Karger AG, Basel Introduction Carol A. Foster, MD 12631 E 17th Ave., Mailstop B205 Aurora, CO 80045 (USA) Tel. +1 303 724 1967, E-Mail carol.foster @ ucdenver.edu Downloaded by: 202.67.40.26 - 5/19/2015 2:52:49 PM Benign paroxysmal positional vertigo (BPPV) is a common vertigo disorder in which otoconia normally adherent to the utricle become displaced into the semicircular canals [Lanska and Remler, 1997; Parnes and McClure, 1992; Welling et al., 1997]. These can be 67. White et al. Usually patients with recurrences return to clinic for further maneuvers. the newly cleared particles are located just outside the opening to the common crus of the semicircular canals. it has limitations. 1992. 2000. 1997]. Other maneuvers have been described for the horizontal and anterior canal variants [Appiani et al. 2004]. 2005]. until no further symptoms can be elicited [Epley..com/aue The Science of Hearing and Balance 17 cleared from the semicircular canals by canalith repositioning (CRP). It is useful to the operator during the Epley maneuver because the nystagmus is enhanced. Ideally a maneuver is applied several times in the course of one treatment session. Although this complication is infrequent. 1988.S. Only the latter is useful when self-applied by a patient. The DH causes ampullofugal fluid and particle movement in the posterior canal. it is possible to have recurrences. nor are they trained in treatment maneuvers for it. 2012].. This can occur in up to 9% of patients during performance of rapidly repeated maneuvers. 2000]. the vertigo and vomiting is severe enough to cause some patients to seek emergency care.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. were independently devised. depicted in written sources. This is usually performed by a clinician or therapist. and it is designed to trigger a particularly severe spell of nystagmus that is thus more easily observed. and are given out by physicians directly to patients who use them to perform exercises at home [Furman and Hain. An exercise that successfully relocates the causative particles without causing dizziness would be preferred from a patient standpoint. Basel www. 1992]..1159/000337947 Published online: April 20.. These maneuvers have been posted on the internet. and both have been found to be similar in efficacy.26 . listed below.. maximizing the sensation of vertigo and the resulting nystagmus [Lanska and Remler.karger. 2004. This is useful in diagnosis because it places the patient’s eyes in a favorable position for viewing by the physician.. If another DH is performed as one of a series of exercises. because it allows diagnosis to take place at the start of a maneuver. 1999]. Radtke et al. In order to be used effectively by patients. The Epley maneuver is popular in ENT practices in the U. which causes dizziness that can be severe enough to cause vomiting. and because it moves the particles in the direction of the canal exit. resolving the dizziness [White et al. but home exercises should be more cost-effective.5/19/2015 2:52:49 PM Foster et al. Karger AG. The ideal home exercise should be able to be performed by the patient without an assistant.40. The initial step in the Epley maneuver is the Dix Hallpike (DH) maneuver. 2012 © 2012 S. The Epley maneuver requires an operator and often a second assistant to guide the patient through the proper positions. Downloaded by: 202.. but patients generally do not have the expertise to recognize differences in nystagmus indicating this disorder.. and have minimal side effects. Casani et al. it is possible for these particles to reflux into the horizontal semicircular canal. two treatments for the posterior canal variant. A 15-min wait between maneuvers reduces the risk of this complication and was used in this study. which exceeds 90% [Epley. but the sequence may be confusing when vertigo is also being experienced. the ideal exercise should be reasonably simple to learn and apply. that may reduce its utility as a home exercise. The Semont maneuver has similar limitations. this is easily diagnosed and treated with H-BPPV maneuvers. 2005]. This may limit the utility of the Epley maneuver as a home exercise. 1992]. Nunez et al. Semont et al. 1999]. When used in a specialty clinic.: Half Somersault . A second limitation is the possibility of horizontal canal BPPV (H-BPPV). because in the absence of a viewer there is no benefit to maximizing nystagmus. creating H-BPPV [Foster et al. After performing CRP successfully. 2011]. In the 1980’s.. The posterior semicircular canal is most sensitive to ampullofugal movements (movement of fluid or particles in the stimulatory direction) and is much less sensitive to ampullopetal movements (the inhibitory direction). which approach 50% over 1–3 years [Beynon et al.2:16–23 DOI: 10.. However. It is possible to self-apply CRP without assistance [Radtke et al. and a number of minor variations of all these maneuvers have been reported. 2001. a variation of which is also used in the Semont maneuver [Epley. 1999.. the Epley and Semont maneuvers. Radtke et al. and is often taught for home use [Radtke et al. Because particles can again become displaced into the semicircular canals over time.. sit up. discomfort during maneuvers. This study compares the Epley maneuver with the half somersault maneuver. tendency for re-entry complications. Patients unable to tolerate the DH or CRP. because these movements are required as part of the exercises. Sixty-eight individuals were enrolled and completed the study. by allowing particles to move against the direction of fluid movement.26 . Typically patients are treated with repeated maneuvers until symptom free at a single visit. The first three positions replace the DH. and the presence and intensity of nystagmus was recorded using a 1–5 scale (nystagmus intensity score). Because it does not include the DH. Although we had long prescribed home exercises based on the Epley and Semont maneuvers for recurrences. or nystagmus of any other direction or stemming from other peripheral or central vestibular disorders were excluded.com/aue The Science of Hearing and Balance 18 Foster et al. Our institution has a weekly BPPV clinic.5/19/2015 2:52:49 PM Patients and Methods . Karger AG. Although the remaining two body positions differ substantially from the Epley maneuver.1159/000337947 Published online: April 20. This was a prospective.: Half Somersault We have devised a novel exercise. There is extensive literature evaluating the efficacy of the Epley maneuver (the current standard of Downloaded by: 202. We see over 200 BPPV patients per year in this clinic and perform maneuvers on all patients with BPPV of either the horizontal or vertical canal varieties.A. bilateral BPPV. Another researcher then removed the subjects to a training room.2:16–23 DOI: 10. single-blinded clinical trial comparing the two exercises for BPPV. Exclusions included patients who were unable to bend the neck or turn the head safely. Diagnosis was performed by direct visualization of the globes during the DH maneuver. Foster).E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. Inclusion criteria were as follows: 18 years of age or older. a history of symptoms suggestive of BPPV. which should slow their transition time and reduce cupular deviation compared to the DH. The study was performed at a tertiary academic referral center from 2007 to 2010.karger. the half somersault (fig. controlled.40. A secondary rationale was to reduce the dizziness experienced while the head is initially inverted. and assigned them via a randomized list prepared by a statistician to either the Epley or the half somersault maneuver. this may reduce the risk of H-BPPV conversion. after introducing this home exercise into our clinic in 2006. lie down.67. the head motions are similar to those used when returning from the side-lying to the upright position in the Epley maneuver. 1) that is able to clear the causative particles from the semicircular canals but does not include the DH or require an assistant. nystagmus and axis of ocular rotation consistent with unilateral posterior canal BPPV. Patients with a history of BPPV symptoms but without visible nystagmus on DH were excluded. roll over or kneel on hands and knees. randomized. and in efficacy as a home exercise. when performed by patients as a self-treatment for posterior canal BPPV. 2012 © 2012 S. Basel www. We wished to determine whether the half somersault and Epley are equivalent in resolving acute nystagmus. or who were unable to assume the half somersault position were excluded. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. All subjects gave informed consent according to a protocol approved by the Colorado Multiple Institutional Review Board (Principal Investigator C. 49 females and 19 males. Patients presenting with cupulolithiasis. H-BPPV. The head positions and corresponding particle positions are shown in figure 2 and the body positions we designed to achieve these head positions are shown in figure 1. A diagnostic DH was performed in a treatment room by the PI. we noticed a decline in the number of patients returning with recurrences. Karger AG. the head is raised to back/shoulder level. Dark curved arrows show Downloaded by: 202.karger. Half somersault for right-sided BPPV. Basel www.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. any dizziness is allowed to sub- side before moving into the next position. E Maintaining the head at 45°.5/19/2015 2:52:49 PM head movements. 1.26 . the head is quickly tipped upward and back. the head is raised to the fully upright position.40.: Half Somersault Fig.67.1159/000337947 Published online: April 20.2:16–23 DOI: 10. Lighter arrows near eyes show the direction one should be facing. to face the right elbow. with the chin tucked as far as possible toward the knee. if there is no dizziness. . C The head is turned about 45° toward the right shoulder.com/aue The Science of Hearing and Balance 19 Foster et al. B The somersault position is assumed. After each position change. A While kneeling. the position should be held for 15 s. D Maintaining the head at 45°. 2012 © 2012 S. the small arrow indicates particles exiting to the utricle.: Half Somersault Fig. with the head inverted. This information was collected by mail and by telephone follow-up. Head positions shown in A–E correspond to body posi- care) versus untreated controls.26 . The posterior canal lies at approximately 50° outside of the sagittal plane and projecting toward the viewer as depicted.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012.2:16–23 DOI: 10. In C . . The PI was blinded as to the maneuver type that the patient had learned and used. We expected that this would reduce the risk of horizontal canal conversion in the Epley group. any cleared particles in the utricle are unable to reflux into the horizontal canal during this step. This included instructions to wait 15 min between each maneuver performed to reduce the risk of canal conversion or re-entry. All patients then waited 15 min prior to returning to the original treatment room. the plane of the horizontal canal is oriented at an upward angle. The experimental group contained those self-treating with the half somersault maneuver. Thirty-five subjects were in the Epley group. In C–E the head rotates 45° from the sagittal plane of the body and the labyrinth is depicted similarly rotated. A = Anterior canal. and the presence. Basel www. Subjects were asked to rate the severity of the dizziness they experienced during their exercises on a 1–5 scale (exercise-induced dizziness score). On repetition of the maneuver. the controls were the patients receiving the Epley maneuver as a home exercise. The angle of view is 90° to the sagittal plane of the head and body in the starting position and in A and B. any patient with continued BPPV then received maneuvers by the PI (Epley) until they were free of nystagmus and experienced one DH without dizziness or nystagmus. 2012 © 2012 S. Small arrows indicate the movement of particles as each position is assumed. This places the posterior canal near the sagittal plane of the body and allows maximal ampullofugal fluid movement as the head is raised. Large bolded arrows in A–D indicate the final location of the particles for each position.5/19/2015 2:52:49 PM tions in figure 1. The subject was instructed in the selected maneuver verbally and with a handout and demonstration. All patients with a recurrence Downloaded by: 202. We defined a recurrence as a return of dizziness for which the patient applied the assigned exercise. In E .67. To complete treatment and meet the standard of care. Karger AG. In this experiment.1159/000337947 Published online: April 20. A handout with written instructions and a diagram of the assigned exercise was given to the subject in a sealed envelope for later home use.karger. The subjects were provided with a log sheet to record recurrences and treatment results and were instructed to perform their assigned exercise with any recurrence. P = posterior canal.com/aue The Science of Hearing and Balance 20 Foster et al. A DH was then performed by the PI. and was observed performing it twice without physical guidance.40. 2. Particle movement during half somersault. H = horizontal canal. duration and intensity of any remaining nystagmus was again recorded using a 1–5 scale. and 33 in the somersault group. 11/68 (16%) of the subjects were lost to follow-up. 3 returned to the clinic because they were unable to resolve their symptoms with the exercise. Karger AG.and post-treatment nystagmus intensity within each group. one continued to have slight dizziness but did not feel it was severe enough to return to the clinic for it. this declined to a post-treatment score of 2. 9/33 (27%) had a complete resolution of dizziness and nystagmus after their two maneuvers. and they were questioned by telephone to verify log accuracy. Subjects reported an exercise-induced dizziness score of 2. In the half somersault group. 10/15 (67%) in the Epley group were able to resolve their recurrent symptoms using the home exercise. The half somersault and Epley groups were compared statistically by unpaired T test for initial nystagmus intensity and post-treatment nystagmus intensity. The lowest possible score of 1 for exercise-induced dizziness was reported by 15/35 in the Epley group (43%) and 23/33 (70%) in the half somersault group and this difference was significant (p = 0. Although there were fewer recurrences in the half somersault group. The scores for exercise-induced dizziness were significantly lower in the half somersault group (p = 0.1159/000337947 Published online: April 20. Downloaded by: 202. Subjects reported an exercise-induced dizziness score of 1. 2012 © 2012 S.023). The highest scores of 4–5 for dizziness occurring during the exercise were reported in 7/35 (20%) of the Epley group and 4/33 (12%) of the half somersault group.: Half Somersault not responding to their assigned exercise were offered a return to one of our weekly BPPV clinics for standard treatments. Six months after initial treatment.57. We defined a treatment failure as a return to the clinic for dizziness after use of an exercise for recurrence.com/aue The Science of Hearing and Balance 21 Foster et al. After two self-performed maneuvers. 9/10 (90%) were able to resolve their recurrent symptoms using the home exercise. This difference was significant (p ! 0.88 (mean 8 SD). Exercise-induced dizziness scores. 13/35 (37%) had a complete resolution of dizziness and nystagmus after performing their two observed maneuvers.61 8 0. Basel www. coupled with an abnormal DH in the treated ear on exam.karger.5/19/2015 2:52:49 PM Results .684).291). this difference was not significant (p = 0. The difference between pre-treatment nystagmus scores for the Epley and half somersault groups was not significant (p = 0.67. The complete resolution rate after two maneuvers did not differ significantly between the Epley and half somersault groups (p = 0. their clinical chart was reviewed for recurrences. The post-treatment nystagmus scores in the Epley group were significantly lower than in the half somersault group (p = 0.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. Paired T tests were used to compare pre.11 8 1.40.004). this declined to a post-treatment score of 1.236). the initial DH resulted in a nystagmus intensity of 3.2:16–23 DOI: 10. The half somersault group was significantly less likely than the Epley group to experience a treatment failure (p = 0. 6 in the half somersault group and 5 in the Epley group.271). numbers of subjects with complete resolution of dizziness after two maneuvers.11 8 1.0001).11. None experienced H-BPPV.034).0001). A significance level of 0. After two self-performed maneuvers.17.049). the initial DH resulted in a nystagmus intensity of 3. and 2 returned to the clinic and discontinued exercises due to H-BPPV.97 (mean 8 SD). a 68% reduction in nystagmus intensity. 21 recurrences occurred in 15/30 (50%) of the subjects in the Epley group and 12 recurrences in 10/27 (37%) of the subjects in the half somersault group. During the 6-month follow-up period. number of recurrences and treatment failures were analyzed by Fisher’s exact test.05 was adopted. In the half somersault group. This difference was significant (p ! 0. In the Epley group.17 8 1.26 . a 42% reduction in nystagmus intensity.51 8 0. the log sheets were collected and each subject was contacted.20.61 8 1. this difference was not significant (p = 0. However. Again. Vertigo is normal during this part of the procedure. or with impaired flexibility.com/aue The Science of Hearing and Balance 22 Foster et al. This position may cause a burst of vertigo. After the vertigo subsides. wait until any vertigo ends. Some additional vertigo may occur. place your head on the floor upside down. Your head should be positioned at about a 45° angle to the floor throughout this move. returned to the clinic for treatment.26 . Tapping firmly on the skull with your fingertips just behind the right ear can help move the particles along. The vertigo means the particles are moving in the proper direction. Downloaded by: 202. Tip your head straight upward quickly until you are looking straight up at the ceiling. the subjects reported more dizziness during the Epley than during the half somersault exercise and this difference was also statistically significant. and only members of the Epley group discontinued using exercises.2:16–23 DOI: 10. C Slowly turn your head to face your right elbow.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. You will keep your head turned to the right through the rest of the maneuver. Our study shows that both exercises are efficacious when used as a home exercise for patients.40. and so does not require that the patient be able to arise from the floor. B Next. slowly sit upright. QUICKLY raise your head to shoulder level. it requires that the patient be able to assume the initial half somersault position. These results suggest that patients prefer the less effective exercise because they experience less dizziness when applying it and experience fewer complications. 2001]. The half somersault can be performed on either the floor or in the center of a large bed.1159/000337947 Published online: April 20. The half somersault was not as effective as the Epley in reducing nystagmus intensity with two maneuvers. Wait for the vertigo to end or count to 15 before continuing.karger. The inclusion of the diagnostic DH at the start of the treatment maneuver makes it particularly useful to diagnosticians. neck or back injuries. The Epley group was significantly more likely to experience a treatment failure using home exercises for recurrences than the half somersault group. although neither is as effective as when the Epley is performed by an experienced operator.. as if you are about to do a somersault. with knee. an indicator of a reduction in particle burden in the posterior semicircular canal.5/19/2015 2:52:49 PM Appendix . For these reasons. wait for any vertigo to end before moving to the next step.: Half Somersault Discussion The efficacy of the Epley maneuver has been demonstrated repeatedly and has led to its widespread use for the clinical treatment of BPPV [Epley. Instructions for half somersault for right-sided BPPV A Kneel on the floor or in the middle of a large bed. 2012]. or experienced H-BPPV. Tuck the chin so that your head touches the floor near the back of the head rather than near the forehead. Try to center the right elbow in your field of view. Karger AG. but the subjects in this study had a resolution rate of only 37% after two Epley maneuvers and 27% after two half somersaults. and so cannot be used by patients of excessive body weight. We typically resolve 84% of BPPV cases in two maneuvers [Foster et al. it is the treatment of choice for posterior canal BPPV in our clinic and in many others. Basel www. and this difference was statistically significant. Without moving. This may cause dizziness briefly. E Raise your head to the upright position QUICKLY. However. They are then able to repeat the exercise enough to resolve symptoms and so may not need to return to the clinic for treatment. D Keeping your head turned to the right and viewing your right elbow. This suggests that patients may have to perform more half somersaults than Epley maneuvers to resolve an episode of BPPV.67. keeping it about halfway turned toward the right shoulder. 2012 © 2012 S. Strong D: Canal conversion and re-entry: a risk of Dix-Hallpike during canalith repositioning procedures.63: 8–9. Foster C.144:412–418. Parnes LS. Mainz-Perchalla A. Baguley DM. Nunez RA. Otolaryngol Head Neck Surg 1992.: Half Somersault Rest for 15 min. Bakaletz LO. quickly tip your head up and down. . Cass SP. O’Brien B. You may also repeat the maneuver if you have another vertigo spell in the future. If you still feel some dizziness when making that movement. White J. References Downloaded by: 202. Laryngoscope 1992.48:1167– 1177.and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Furman JM. Basel www.2:16–23 DOI: 10.26:704–710. Neuhauser H. 42:290–293. Semont A. do not repeat the maneuver. Cerchiai N. Epley J: Human experience with canalith repositioning maneuvers.5/19/2015 2:52:49 PM Appiani GC. Otol Neurotol 2001.com/aue The Science of Hearing and Balance 23 Foster et al. Ann N Y Acad Sci 2001. Brackmann DE. and conceptual developments [see comment]. After the rest. Otolaryngol Head Neck Surg 2011.1159/000337947 Published online: April 20. Savvides P.40. If no dizziness occurs. Radtke A. Casani AP. Welling DB. Cherian N.E X T R A Audiology Neurotology Audiol Neurotol Extra 2012. Laryngoscope 1997. Radtke A. Disclosure Statement No financial disclosures for any author. Remler B: Benign paroxysmal positioning vertigo: classic descriptions. Neurology 2004. J Otolaryngol 2000. Parnes LS. Lempert T: A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo [see comment]. Hinojosa R: Particulate matter in the posterior semicircular canal. da Cruz MJ: Recurrence of symptoms following treatment of posterior semicircular canal benign positional paroxysmal vertigo with a particle repositioning manoeuvre. Freyss G. Gagliardi M: A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo [see comment]. 2012 © 2012 S. Sellari-Franceschini S: Anterior canal lithiasis: diagnosis and treatment. Dallan I. Lanska DJ.karger.26 . Lempert T: Self-treatment of benign paroxysmal positional vertigo. Vitte E: Curing the BPPV with a liberatory maneuver. repeat the maneuver.107:399–404. Neuhauser H. Epley JM: The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Tiel-Wilck K. Hain TC: ‘Do try this at home’: self-treatment of BPPV [see comment]. Sleep propped up on 2 or 3 pillows for two nights following the maneuver. Karger AG. Beynon GJ. Catania G. origins of the provocative positioning technique. Zaccaro K.29:2–6.53:1358–1360. Adv Otorhinolaryngol 1988. Furman JM: Short.33:199–203. von Brevern M. Otol Neurotol 2005.107:90–94. von Brevern M.122:647–652. McClure JA: Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion.67. Otolaryngol Head Neck Surg 2000.102:988–992.942:179–191. Sleep only on your left side for a week after the maneuver (put a pillow behind you to keep you from rolling over in the night). Neurology 2004. Otol Neurotol 2012. Neurology 1999.63:150–152. Oas J: Canalith repositioning for benign paroxysmal positional vertigo.22:66–69. Neurology 1997. Additional instructions Always wait at least 15 min between maneuvers to allow particles to settle.